Nokea
The nurse writes the client problem of 'acute pain and itching secondary to bacterial skin lesions.' Which interventions should be included in the care plan? Select all that apply.
- A. Keep humidity at less than 20%.
- B. Maintain a cool environment.
- C. Use a mild soap for sensitive skin.
- D. Keep lesions covered at all times.
- E. Apply skin lotion after bathing.
Correct Answer: B,C,E
Rationale: Cool environment, mild soap, and lotion reduce itching and pain in bacterial lesions. Low humidity worsens dryness, and constant coverage may trap moisture, promoting infection.
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Before leaving the room, which of the following nursing access to the nurse's place, the client's place.
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.
The nurse is assessing the client with atopic dermatitis. Which finding should the nurse expect?
- A. Patchy loss of skin pigmentation called vitiligo.
- B. Trichotillomania, a type of hair loss from compulsive pulling and/or twisting of the hair.
- C. Blistering, redness, and a white patch between the fingers, characteristic of candidiasis.
- D. Atopic dermatitis, which is characterized by redness and irregular, scaly lesions.
Correct Answer: D
Rationale: Atopic dermatitis is characterized by redness and irregular, scaly lesions. Vitiligo shows patchy loss of pigmentation. Trichotillomania involves hair loss from compulsive pulling. Candidiasis shows blistering, redness, and white patches.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, 'What is a xenograft?' Which statement by the nurse would be the best response?
- A. The doctor will graft skin from your back to your leg.'
- B. The skin from a donor will be used to cover your burn.'
- C. The graft will come from an animal, probably a pig.'
- D. I think you should ask your doctor about the graft.'
Correct Answer: C
Rationale: A xenograft uses animal skin (e.g., porcine) for temporary burn coverage. Autografts use the patient’s skin, allografts use donor human skin, and deferring to the doctor avoids education.
When the nurse inspects the client's eyes, which clinical finding is most indicative of cataracts?
- A. Ruptured blood vessels in the eye
- B. An irregularly shaped iris
- C. A white spot behind the pupil
- D. A painless corneal lesion
Correct Answer: C
Rationale: A white spot behind the pupil indicates lens clouding, characteristic of cataracts.
Which statement would the nurse expect the client to report when looking at an object without wearing corrective glasses or contact lenses?
- A. I see near objects more clearly.
- B. I see a blurry area in front of me.
- C. I see far objects more clearly.
- D. I see two of the same object.
Correct Answer: B
Rationale: Astigmatism causes blurry or distorted vision due to irregular corneal curvature.